Abstract
Aim
To evaluate the impact of a co-designed intervention to reduce time spent on clinical documentation and increase time for direct patient care.
Design
A pre- and post-test interventional study with multi-method evaluation, reported according to the Transparent Reporting of Evaluations with Nonrandomised Evaluations Designs guidelines.
Methods
An intervention to decrease the burden of documentation was co-designed and implemented. Pre- and post-intervention data were collected via time and motion studies and the Burden of Documentation for Nurses and Midwives (BurDoNsaM) survey. Documentation audits were conducted to assess intervention fidelity.
Results
Twenty-six shifts were observed (13 pre-intervention, 13 post-intervention). Although the coronavirus pandemic contributed to decreases in staffing levels by 38% (from 118 to 73 staff), the number of task episodes completed increased post-intervention, across all shift patterns. Documentation took less time to complete post-intervention when assessing time per episode. A mean increase of 201 episodes was observed on morning shifts, 78 on evening shifts and 309 on night shifts. There were small increases for time spent on direct patient care compared to pre-intervention but there was less time per episode. Results from the BurDoNsaM survey indicated that participants felt documentation took less time post-intervention. Documentation audits found completion improved as staff gained familiarity, but deteriorated when staffing levels were reduced.
Conclusion
The intervention was able to reduce time spent completing documentation, increasing the time available for direct patient care.
Implications for the profession and/or patient care
Completing clinical documentation is part of the daily work of nurses and midwives. Clinical documentation needs to accurately capture key information in a concise and streamlined manner to avoid unnecessary burdens and release time for direct patient care.
